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 CSD 5200

Dysphagia Management


Oral preparation phase

Oral phase

Pharyngeal or laryngeal paralysis

Management Questions

Goal of management

 Continuous goal of any treatment program is the re-establishment of oral feeding while constantly maintaining adequate nutrition.

 Oral vs Non-Oral Feeding

Should pt continue to be fed orally or should pt be placed on nasogastric tube or given a gastrostomy?

Factors to make decision:

  • Time - Logemann, Wheeler & Sisson (1979) examined the relationship between speed of swallowing and diet choices. Pt had oral cancer. Measures of oral and pharyngeal transit time taken 1, 2, 3, and 6 month intervals were compared with food consistencies actually included in pt's diet.
    • Results - Particular food consistency is not part of pt's diet unless combined oral and pharyngeal transit time for swallow is approximately 10 seconds or less.
    • Implications - If pt takes more than 10 seconds to eat every consistency of food tried, pt may feed by mouth but will need a nasogastric tube to supplement oral feedings and to provide adequate nutrition. Decision to use gastrostomy is based on length of non-oral feeding (3-4 wks or longer).
  • Aspiration - Pt who is aspirating more than 10% of every bolus, regardless of consistency of food, should not be feed orally.

Direct vs Indirect Treatment

Indirect Therapy

Oral Motor Control Exercises

Tongue Control Problems
  • difficulty with lateralization of tongue during chewing
  • elevation of tongue to hard palate
  • cupping of tongue around bolus
  • elevation of tongue against palate to hold bolus
  • range of anterior to posterior movement of tongue in initiating
  • oral stage of swallow.
  • organized anterior to posterior tongue movement to initiate swallow.

 Range of Tongue Motion Exercises

  • Amount of exercises
    • repeated 5 - 10 times in one session (3-4 minutes)
    • entire set of exercises repeated 5 - 10 times per day
  • Tongue elevation - hold it for 1 sec and release
  • Tongue lateralization - hold it for 1 sec and release
  • Tongue anterior-posterior range - hold it for 1 sec and release

Resistance Exercises

  • pushing tongue against a tongue blade, popsicle, sucker, finger. Push up, side, and forward for 1 sec at maximum range of movement.

 Bolus Control Exercises

 Gross Manipulation of Material
  • Flexible licorice whip should be used. Pt can manipulate one end of licorice with tongue while clinician holds other end.

Gross movement - after each attempt, pt should judge success and indicate location of bolus/ When pt is able to make movements with speed (3 directions in 1 sec), use other materials.

  • side to side
  • forward and backward
  • circular fashion
  • middle to side
  • back to middle
  • middle to side

Materials

  • licorice
  • life saver with string
  • thin cloth tape soaked in juice
  • chewing gum without clinician's control

 Hold a Cohesive Bolus 

  • Begin with paste bolus (1/3 tsp) place bolus on tongue and pt is asked to move bolus around the mouth, without losing material allowing it to spread out around the mouth. This requires pt to cup tongue around bolus. When pt is finished, can expectorate bolus and clinician can examine mouth for residue. Move on to larger amounts when successful.
  • Then move to liquid bolus.

 Bolus Propulsion

  • Posterior propulsion of bolus. This can be accomplished using a narrow wad of gauze soaked in juice. Pt asked to push upward and backward against the gauze with tongue, squeezing liquid out of gauze and pushing it backward at same time. Clinician maintains controls of gauze. Amount of liquid placed on gauze is dependent upon pt's ability to control liquid.

Stimulate the Swallowing Response

Triggering of reflex initiates simultaneous motor acts:
  • elevation of soft palate to close of vp port
  • elevation and closure of larynx to close off airway
  • contraction of pharyngeal constrictors to initiate peristalsis
  • relaxation of cricopharyngeal muscle at top of esophagus

Procedures

  • If pt can tolerate liquids, use pipette to introduce liquid (1/4 in Ice H20)
  • Severely impaired pts - 4-5 times daily for 5-10 minutes for several wks-mon
  • Once swallow triggers increase amount of material in single swallow changing consistency from liquid.

 Exercises to Increase Adduction of Tissues at Top of Airway

If laryngeal incompetence can't be manage quickly by postural assists or teaching pt to voluntarily close the airway, a sequence of laryngeal adduction exercises should be initiated prior to any actual swallowing therapy.

 Procedures

  • Hold his breath as tightly as possible while pushing down or pulling up on chair with both hands for 5 sec. Repeat series 5-10 times per day for 5 minutes each time.
  • Pt is asked to bear down against chair with 1 hand and produce clear voice simultaneously 5 times.
  • Repeat "ah" 5 times with hard glottal attack on each vowel.
  • Can monitor improvements in laryngeal function by listening to voice clarity
  • Repeat this sequence 3 times, 5-10 times per day.

Pseudo Supraglottic Swallow

  • take a breath, hold it, and cough as strongly as possible. In this way, pt practices adduction/expectoration steps of supraglottic swallow. Can incorporate this procedure into entire supraglottic procedure with holding breath while swallowing. Most pts will learn procedure in 2 wks, but airway protection may 6-8 months. Successful with supraglottic laryngectomy.

Direct Therapy

involves presenting food or liquid to pt and asking him to swallow it following specified instructions. Only small amounts of food should be given to prevent airway obstruction. Coughing should be positively reinforced as pt may view coughing as a sign of failure to swallow correctly.

Mastication

Reduced range of tongue movement laterally
  • Exercises
    • Indirect exercises
  • Temporary measure
    • Mash food by pressing tongue against roof of mouth
  • Position
  • position food on most mobile side of tongue

Reduced buccal tension/buccal scarring

  • Exercises
    • rounding lips "oh"
    • stretching lips broadly "ee"
    • alternating two postures may increase tension
  • External pressure on affected cheek
  • Position - Placing food on unaffected side
  • Posture-Tilting head towards unaffected side

Reduced range of mandibular movement laterally

  • Exercises involve opening jaw as widely as possible and holding maximum opening for 1 second; opening and moving jaw to each side as far as possible and holding extended position in each direction for 1 second; moving jaw around in a circle as far as possible.
  • If unable to lateralize, and thus normal occlusion, teach mashing food with tongue against palate in order to broaden diet options.

Reduced range of tongue movement vertically

  • Exercises
    • Indirect exercises
  • Palatal prosthesis
    • Mandibular prostheses used to improve oral manipulation of food and speed of oral transit.

 Preparatory Phase

Reduce labial Closure
  • Exercises
    • stretching lips in /i/ position and holding for 1 sec
    • puckering lips as tight as possible and holding for 1 sec
    • bringing lips together and holding for 1 sec
    • if closure is not possible, close lips against spoon or object, increase time required to maintain closure
    • 1 minutes 10 times/day
    • 2 minutes 10 times/day
    • 10 minutes per time
  • Buccinator apparatus

Reduce tongue movement to form bolus

  • Exercises
    • indirect therapy
  • Interim measure
    • Posture-tilt head forward to keep bolus in anterior part of mouth until ready to initiate swallow. At start of swallow, pt changes posture as appropriate.

Reduced range and coordination of tongue movement to hold bolus

  • Exercises
    • indirect therapy
  • Interim measure
    • Position-Hold material securely against front of roof and swallow immediately. Do not manipulate bolus.
    • Posture-Head tilted downward to keep bolus in anterior position

Reduced ability to hold bolus in normal position 

  • Give paste bolus and ask pt to hold bolus against anterior to mid portion of palate with tongue.

Reduced oral sensitivity

  • Position-food on more sensitive side of oral cavity.
  • Temperature-use of cold liquid may help localize material in mouth.
  • Taste-use of mild spices or tastes may improve sensitivity to localization.

Oral Phase

 Tongue Thrust
  • Awareness and self monitoring - For neurologically impaired pt who acquires a tongue thrust, heightening awareness of pattern and asking them to consciously position their tongue on alveolar ridge and begin swallow with an upward-backward push will often reduce the thrusting.
  • Compensatory measure - place food posteriorly on tongue

Reduced Tongue Elevation

  • Exercises
    • Indirect therapy
  • Interim measure
    • Position-food posteriorly
  • Compensation-use syringe and bypass necessity of tongue elevation use straw for pt who can suck
  • Posture-Head tilted backward to allow gravity to assist in propelling food from oral cavity to pharynx.
  • Sequence for aspiration
    • Hold breath
    • Place food in mouth
    • Tilt head backward and swallow
    • Cough after swallow

Reduced Anterior to Posterior Tongue Movement

  • Exercises
    • Indirect therapy
  • Interim Measures
    • Same as reduced tongue elevation

Disorganized Anterior to Posterior Tongue Movement

  • Alert pt to hold bolus against palate with tongue and initiate swallow

Scarred Tongue Contour

  • Cannot be improved with exercises
  • Compensation-Position food posterior to scarring
    • Tilt head backward to use gravity to assist in oral transit

Pharyngeal Phase

Delayed or Absent Swallowing Reflex
  • Exercises
    • Indirect therapy
  • Compensation
    • Tilt head forward when swallowing - widens vallecular space and increases chance that bolus will hesitate in valleculae prior to triggering of reflex rather than fall into airway. Should also limit amount of bolus so the bolus can be held in pharyngeal recesses and prevent overflow into airway.
    • Speed-Determining speed at which pt swallows is important. Pt warned about time needed between swallows to insure bolus has cleared pharynx before a new swallow is initiated.

Reduced Pharyngeal Peristalsis

  • No direct therapy techniques to improve peristalsis
  • Compensatory techniques -
    • alternating liquid and semisolid or solid swallows so liquid washes residue away.
    • limiting diet to liquids or thin paste materials requiring less peristaltic action to clear pharynx.
    • following each swallow with dry swallows
    • teaching supraglottic or airway protection may be helpful

Unilateral Pharyngeal Paralysis

  • Compensatory Techniques
    • Turn head to affected side - thus closing pyriform sinus on affected side and directing material down the more normal side.
    • Lingual Dysfunction- tilt head toward stronger side, thus keeping material on stronger side in oral cavity as well as the through the pharynx.
    • Supraglottic swallow - in order to expectorate residue
    • Use alternate liquid and solid swallow

Cervical Osteophyte

  • bony overgrowth of cervical vertebra must be surgically removed.

Scarred Pharyngeal Wall

  • Same technique for unilateral paralysis
  • Supraglottic sequence may help with removal of residue

 Scar Tissue at Base of Tongue

  • With laryngectomees, scar tissue widens with pull of pharyngeal constrictors and acts as a pocket.
  • Surgically removed
  • Adjust to swallowing only liquids and thin paste consistencies

Reduced Laryngeal Elevation

Reduce Laryngeal Closure

  • Exercises
    • Indirect Therapy
  • Supraglottic Swallow
  • Posture-Forward head posture during swallowing widens valleculae space
    • Supraglottic laryngectomee- will not work as epiglottis has been resection
    • Turning head to nonfunctional side may improve closure

Cricopharyngeal Dysfunction

  • Myotomy (slit muscle)
  • Dilation involves passage of mercury filled soft rubber tubes of increasing diameters to gradually stretch it open. Temporary effects lasting 1 month.

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